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e <br /> sous e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> •Cit JfOR N.r <br /> COMPLETE THIS FORM FOR EAC ACILRYISITE <br /> MARK ONLY F—] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 1:1 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 98 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA,9R FACILITY NAME N OF OPERATOR <br /> Po o -ung P P Di J Mite, (,Jh I+e- <br /> ADDRESS REST CROSS STREET PARCEL#(OPTIONAL) <br /> lqc)5 Coun+r cmb In <br /> CITY NAM O STACEA ZIP�ODE SITE PHONE u WITH AREA C <br /> 5 _QDE <br /> tt�`✓�J�J BOX (�/, LO <br /> TO INDICATE COR ATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS EV 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF J>4T SITE i E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: AM (LAST,FI T) PHONE# ITH AREA CODE DAY§: NAME(LAST,FIRST) <br /> l� I e 5 e Z 3 -Z Z v✓ ! n <br /> NIGHTS: NAME(L T,FIRST) PHONFr#WITH AREA COPE NIGHTS: NA E(LAST,FIRST)) <br /> (05(0 r i 47n6nali <br /> II: PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAtj CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRAS ✓ bo indicate Q INDIVIDUAL Q <br /> Q Q LOCAL-AGENCY STATE-AGENCY <br /> ro5 Ci �,� rive, CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY MESTA E ZIP CODE HONE#WITH AREA CODE <br /> Q, Cki o � a � d / 3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ��J n CARE OF ADDRESS INFORMATION <br /> G � d 1�'\ <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1 . <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 74 - 0 1,7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE ETHOD(S) USED <br /> ✓ box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE EV 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.V II.7 III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYN5 <br /> —R -7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# C JURISDICTION# FACILITY# <br /> a Hlogl�. 03 3 Rl <br /> LOCATION6D -OPTIONAL CE SUPVI! -DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR'MR PERMIT APPLICATION- FORM B UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />